Wednesday, April 13, 2016

I Call Bullshit

I don't often call out patients.  Something about bedside manner that we sort of learned in medical school.  But a recent encounter with a patient makes me think maybe we should all do it more often.

I was sitting in a multidisciplinary assessment of a patient in a clinic where I work sometimes.  Now I believe many of this patient's concerns about her condition are quite valid and I have a lot of sympathy for her plight. 
She was going on about how for health reasons she only buys food directly from farmers she knows or eats game that her husband and she hunt or is hunted by people they know.  I have no problem with this.  I like to buy some but not all of my food at farmers markets often paying 50% more and while I don't hunt, I am not against hunting and if somebody offers me game I always take it.  I should support somebody who is trying to be pro-active about their health.  Except.....

She smokes 2 packs of cigarettes a day despite now having COPD.  

I had been letting my colleagues run the interview until the alarm from my BD became too loud in my head.  5 years of administration has increased my BT but this was too much.

"If you are concerned so much about what you eat," I said, "why do you continue to smoke, given all the harmful chemicals in cigarette smoke."  She replied that she had smoked for 30 years and was unable to stop.  The visit went on and I don't believe she came back for a follow-up.  OK, I am busy enough and maybe I couldn't have helped her anyway.  I also appreciate how difficult giving up smoking is, because really with all the evidence about how dangerous it is to your health, everybody who is capable of stopping has.  

A few years earlier, I had another almost identical  patient and never challenged her on this but maybe I should have.  

This encounter made me think however.  Are we hurting patients by not challenging them on their beliefs or behaviours.

A good example is the resurgence of vaccine-preventable diseases.  Now many of the patients/parents are not going to listen to reason, however how many family docs or paediatricians knew of patients in their practice, who had not been vaccinated and never challenged this because calling bullshit goes against our concepts of bedside manner plus you depend on the income from their office visits (and if you are in a small town, the visits of their friends and relatives).   Sure, most of them wouldn't have listened but maybe a couple would have.   Call bullshit. 

Obesity.   Look I weighed myself yesterday and I am pretty upset with what I found, not that I am going to forgo the Chinese buffet for lunch today.  But when your BMI 60 patient tells you, they do know why they can't lose weight because they don't eat anything, why not tell them that just to maintain that weight they need to consume 6000 calories a day and unless they have evolved to develop the capacity to photosynthesize, something is obviously going into their mouths.  And when they say they can't exercise because of their knee or back pain, tell them that exercise doesn't work without caloric restriction.  I have a lot of sympathy for fat people because I am one of them and I know how easy it is to gain weight and how difficult it is to keep it off but the odd person does this successfully and if you don't challenge them they might not get started.  So call bullshit.

Drug allergies.  A few years ago while still department head, I got a letter from our Patient concerns office.  Apparently a patient had presented for surgery with multiple anaesthetic "allergies".  Instead of trying to give an anaesthetic with the 3-4 remaining drugs she was not allergic to yet, my colleague called bullshit resulting in a complaint.  (In my response I called bullshit on the surgeon, who should have had this taken care of before the patient reached pre-op holding.  Sure as a urologist, he probably didn't talk to her but with these patients the "allergies" are usually the first thing they tell you about.)  Likewise my colleague who argued with a patient about her morphine allergy.  He got written up despite giving the patient dilaudid intra-operatively.  Then there is the adrenaline allergy which I saw a couple of weeks ago.  The patient said it makes his heart beat fast.  What happened of course was during an adventure in the dentists' chair a little or a lot of local with epi went intravascular, as happens even with good dentists, and instead of manning up and telling the patient this, the dentist took the cowardly route and told the patient he had an allergic reaction.  So if this patient actually has a real anaphylactic reaction under my care, am I going to go searching around for vasopressin or whatever else might work?   No of course, I am going to call bullshit and use adrenaline.  Likewise the local anaesthetic  "allergies" after a misadventure in the dentists' chair.  Penicillin allergies?  Years ago I almost killed a child with vancomycin because of a "penicillin allergy"  ( it was my resident but I am old school and take responsibility for what trainees under my supervision do).

And of course when the patient mentions how great his chiropracter/naturopath/homeopath is, call bullshit and remind them that when they have a medical problem at 3 am it won't be any of those 3 seeing them.  This also applies to conventional practitioners.  When you patient refuses to take your medication because of something the pharmacist told him, remind him that you went to university the same number of years as the pharmacist BEFORE you went to Medical School.  (I call bullshit on myself here; I only did 3 years of undergrad before going to Medical School).  Having said this, I do work closely with pharmacists and have gotten a lot of good ideas from them.

Surgeons who want to do cases after hours because patient has cancer.  Sorry unless it's an obstruction or a pathological fracture.  I already blogged on this.  Doing the surgery tonight or on the weekend makes no difference to your patient's survival and I am sorry that your patient got cancelled earlier because they misunderstood the NPO instructions or they had medical issues or as is usually the case, your list ran over because you still haven't figured out how slow you really are but after hours is for broken bones, appendicitis etc.  Likewise the guy who presented with renal colic 2 weeks ago but is now pain-free and afebrile; not an emergency.  I call bullshit.

Surgeons who game what after hours prioritization system you have decided to use so that they can do their cases when it is convenient for them.   Surgeons who bring in cases off their wait list to make their on call financially worthwhile.  I call bullshit.

And of course admin.

I now wish that during all the meetings I attended, instead of staring at the ceiling and feeling the spirit ebb from my body, I had just kept on chanting bullshit, bullshit, bullshit.

I call massive C Diff, enterococcus filled bullshit on just about everything Infection Control does.

No money for anaesthetic machines but you want to put a Pyxis in every OR.  I call bullshit.

Calling bullshit on admin, as I found out doesn't work which is why I have all this free time to write a blog.  Not that I discourage it. 

Saturday, April 9, 2016

Reefer Madness Part 4 and Another 15 Minutes of Fame.

I just attended the annual meeting/course put on by the Canadian Consortium for the Investigation of Cannabiniods which I joined a couple of years ago.  I have prescribed/authorized medical marijuana for patients since 2001.  I do so in the context of my chronic pain practice and with some hesitation. 

A week or so on what must have been a slow news day our local paper announced in a front page headline story that a medical marijuana clinic was opening in our city.  Having commented on medical marijuana in the past, I had a feeling that I was going to be hearing from the Fourth Estate pretty soon.  

While I do provide authorization for medical marijuana in appropriate patients,  I have a jaundiced view of medical marijuana clinics.  Over the past few years patients have informed me that for $400 a clinic somewhere else in Canada will give them a "Skype interview" after which they will get an authorization for medical marijuana (under the old regulations) and usually are able to buy product from the affiliated grower.  

I am not sure what the Skype interview consists of; holding their wallet up to the camera on their computer maybe.  This is sleazy practice, and I usually offered to complete the paperwork for "free" if I think they are appropriate candidates.  

There have been incidents like this:

I also increasingly believe that chronic pain should be managed in a multidisciplinary fashion not in silos of care such as medical marijuana clinics or for that matter the block shops we have in our city.  Unfortunately opportunities for multidisciplinary management are difficult because while health care in Canada is "free", physiotherapy and psychology are not.  Further for lack of resources, I and the loosely affiliated group of physicians I practise with  have an 18 month wait list for consults which even by Canadian standards is excessive. 

Our thankfully former Tea Party government who were of course anti-drug were most distressed by the concept of anybody using marijuana but were bound by a court decision, so came up with a solution that is probably the one thing in their 10 years in office that actually worked.  Instead of patients trying to grow their own marijuana (which most of them were not very good at) buying it on the street or from the lone government approved supplier, growers would be able apply for licences to supply patients who would get "prescriptions" from doctors.  I had previously discussed this in another blog.  The advantage of this system is that patients can now buy cannabis from facilities that are inspected by the government and that the THC and CBD content of the product is known which allows doctors and patients to select products of known potency.  This has resulted in about 30 companies, some large and some small being able to provide medical marijuana and according to the man from Health Canada there are 2000 applications to become licenced producers.  

Anyway, it wasn't long before I was contacted for an interview.  This came from a reporter from one of the free newspapers people read on the bus or in coffee shops.  A little down market from my usual encounters with the press but there is no bad publicity.   I basically told him what I had said above.  I said for reasons above that the medical marijuana clinic would have very little impact on the treatment of chronic pain.  I also said that what should have been the headline was the distressing lack of resources for treating chronic pain.  Further I said that while I hoped the physician starting the clinic had the noblest of motives, many people in the past had exploited the vulnerable chronic pain population.

The interview lasted about 10 minutes of which a few sentences made the article.  You can probably find it on Google but I am not going to help you.  It did state that I said there was no need for new physicians to prescribe medical marijuana because there were already enough in our city which I don't think I said. 

The entrepreneur/physician got to comment the the next edition of said free newspaper in which he claimed in messianic fashion that our city had been selected of all the cities in Canada because there was a need for doctors to prescribe medical marijuana.  I don't really think we are better or worse than anywhere else in Canada and he may have other motives for adding to his chain of clinics such as availability of office space or maybe he has a girlfriend in our city.  

I must say I only read these articles fully on line just now while writing this blog.

My next interview request came from CTV and they wanted to interview me on TV.  I took a media relations course a long time ago and the one thing that stood out was using the interview to advance your agenda.  Unfortunately when they contacted me I was on my way to Toronto to attend the above meeting but we agreed that maybe I could be interviewed by Skype in Toronto which I agreed to and I spoke with the reporter on phone and basically told her what I had told the free newspaper reporter only having had time to reflect in more polished form.

I was subsequently contacted by CBC French who wanted an interview which I did on the phone in English from Chilie's in the Calgary airport where I was having a beer and a burger before flying to Toronto.  I was on a roll by then and gave what was probably the best interview of my life.  Too bad I don't listen to CBC French.

Just before my plane took off, I got an email from CTV stating that they were going to cancel the interview because of lack of time.  I suspect the real reason was they realized that I wasn't going to talk about medical marijuana (which is sexy) but was going to talk about chronic pain (which is not sexy except when people smoke dope).

As I have said during this time I was getting ready to go the CCIC meeting in Toronto and just happened to look at the program and discovered that my entrepreneur friend was one of the speakers. Interesting, I thought I will at least get to put a face to name.  I was a little worried because as above I maybe hadn't been that positive about his little business and he had probably read my comments.  I went to two talks by him and he is pretty smooth and I am not sure what to make of him.  I probably should have taken him out for a beer (or smoked a doobie with him) to welcome him to our medical community.

The only blowback I got during the meeting was at lunch on the second day when someone sat down at my table looking at my nametag and said, "Oh you're the guy who thinks your city doesn't need a medical marijuana clinic."  I said something about how it was a 10 minute interview and they had taken out a few sentences and the moment passed.

Otherwise it was a great meeting with some really good talks and I learned a few pearls.  Unfortunately the meeting was essentially preaching to the choir although there were some people who were really pro cannabis.   It would certainly be nice if the people who oppose medical marijuana attended meetings like this and maybe we could have a dialogue.  

The other interesting thing was that the meeting was heavily sponsored by medical marijuana companies and there was a pharmaceutical trade show.  No free samples though.